ATTACHMENT B

YANSAB

SUPPLEMENTAL INFORMATION GUIDE

This form is to be used as an aid in determining employee's ability to wear a respirator.

Respiratory Program Administrator Name:

Employee Name:

Type of respiratory equipment to be used: (air purifying)

SAR (airline)
SCBA
other:

Approximate weight of respiratory

equipment:

Duration and frequency of respirator use: Duration rescue/escape

Frequency routine use

Expected physical work effort: light

moderate
heavy

Additional protective clothing and

equipment to be worn:

Expected temperature:
Expected humidity:

Respiratory Program Administrator

Signature:
Date:

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